Journal of Education and Practice www.iiste.

org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

Impact of Night Shift and Training Development Factors on

Performance of Professional Nurses in North West Bank
Governmental Hospitals
Mr. Ahmad Ayed1 Mrs. Ahida Saleem Thulth2 Dr. Sumaya Sayej3
1. Nursing department, Arab American University, Palestine
2. Al-Watani Governmental hospital, Ministry of health, Palestine
3. Nursing Department, Al-Quds University, Palestine

Abstract
Background: Organizational factors are considered to be the cornerstone in achieving psychological and
professional security at work, which in turn are positively reflected in job performance both quantitatively and
qualitatively. Aim of the Study: The study aimed to assess night shift and education / training developmental
factors on performance of professional nurses in north West Bank governmental hospitals. Subjects and
methods: A quantitative descriptive study utilized stratified random sampling of 185 nurses. A self administered
questionnaire was developed with a response rate of 97%. The questionnaire was validated by experts, and
reliability was obtained by Cronbach’s alpha coefficient was (0.86) Data were analyzed using SPSS. Results:
The overall level of night shift factor affecting performance of professional nurses was high (79.0 %) and ; the
education / training developmental factors moderate (68.8%) as perceived by nurses. It was found that there are
significant differences at α = 0.05 between the total score of night shift and education / training developmental
factors towards workplace in favor to Dr. Nazal Hospital. Conclusion and recommendation: The night shift
and education/ training developmental factors affected the performance of the professional nurses. The findings
of this study provide recommendations and suggestions to improve the performance of professional nurses in
governmental hospitals such as: reduce the strain of long work hours on night shift and motivation t. Providing
continuous professional development of nurses in service training program.
Keywords: night shift, education / training development, professional nurse, Performance.

1. Introduction
Within Palestinian health care many employees perform quality health care that helps to maintain or restore
patient's health; however, far too many do not. Performance problems are reflected in a wide variation, like the
effect of organizational factors that negatively affect the patient's satisfactions. A health care quality
improvement is to maintain what is good about the existing health care system while focusing on the areas that
need improvement. Improving the quality of care and reducing medical errors are priority areas for the
Palestinian governmental hospitals (MOH report, 2011). There are many variations of health care system around
the world; the goal for health care system according to the world health organization report (2011) is to
improving performance and responsiveness to the expectation of the population. Health care systems are
organizations established to meet the health needs of target populations; it is the diagnosis, treatment, and
prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is
delivered by practitioners in medicine, physicians, nursing, pharmacy, allied health, and other care providers. It
refers to the work done in providing primary care, secondary care and tertiary care, as well as in public health
(WHO report, 2011). Health care system in Palestine is a combined entity of all resources actors and institutions
related to the financing regulation and provision of all activities whose primary intent is to improve or maintain
health; it is an arrangement in which health care system is delivered (MOH report, 2011).
Nurses are health care professionals who focus on the care of individuals, families, and communities so
they may attain, maintain, or recover optimal health and quality of life from conception to death WHO health
report (2011). Nurses in the occupied Palestinian territory, work in a large variety of specialties where they work
independently and as part of a team to assess, plan, implement and evaluate care (MOH report, 2011).
According to MOH Report (2011) nurses are the largest health care providers within governmental
hospital, constituting (332) of those 24% professional nurses, in the north part of West Bank where they work in
a variety of settings. Therefore it is important to highlight factors that affect their performance and most
importantly the organizational factors. Organizational factors are linked to –day to- day environment where
health workers carry on their duties (Awases, 2006) and their level of nursing performance may be affected by
the following but not limited to; organizational factors work load, night shift work, availability of resources,
education and training development and manager support which ultimately affects patient’s satisfaction,
organizational vision and mission and the health care situation in Palestine. Some of these factors are identified
and selected for assessing their effect on nurses’performance. These factors were selected based on previous
studies and literature review was found that more focus was on these factors in addition to the political situation

50
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

in Palestine plays a large role in these factors, such as increasing the demand for health insurance and
dependence on international aid.

Effects of night shift on professional nurse's performance:

Page (2004) found that night shift can affect nurses’ performance & patient satisfaction, as for example, nurses
who work at night or who rotate shifts make more error from fatigue than do nurses on other shifts, and the risk
for error can increase by two to three times when nurses work 12.5 hr or more in succession Ohida, et.al. (2001)
examined the influence of day, afternoon, night and rotating shifts on nurses job performance and stress, where
the results indicated that job performances and satisfaction was less on a rotating roster than on a fixed roster.
Although there has been a move towards studies of nursing turnover, there is still a general absence of research
that attempts to associate perceptions of night duty with job satisfaction and ultimately staff turnover.
Researchers consistently identify a relationship between hours worked, nurse fatigue, and errors; with
error rates doubling at 10 hours of work and tripling at 16 hours (Institute of Medicine (IOM), 2004; Rogers,
et.al 2004). Fatigue is often characterized by a decreased ability to complete work and a subjective complaint of
feeling tired. Inadequate rest, sleep loss, and shift work schedules often contribute to fatigue (IOM, 2004).
Fatigue has been reported to produce slowed reaction time, omission errors, impaired problem-solving abilities
and attention lapses (Van-Griever & Meijman, 1987). Furthermore, fatigue may diminish productivity and lead
to errors and accidents
Akerstedt (1996) said that sleep is one of the main reasons why irregular hours cause ailments and
disorders extended waking leads to tiredness and reduced functional capacity. After the first 24 hours without
sleep the functional capacity may be halved and after two sleepless days, the functional capacity is at its lowest
and risk of falling asleep is ever present. With prolonged exposure, the individual cannot manage to keep awake,
and can't make complex decisions which require thinking. Allen (1999) non experimental research studies
examined the effect of sleep on short term memory recall in day shift versus night shift nurses and found that
there is no effect of lack of sleep on cognitive process of short-term memory recall.
Akerstedt et al.,( 2004) An increasing body of evidence exists related to fatigue, sleep deprivation, and
the circadian time of day with their effects on performance and learning and memory function. Although little
research has focused specifically on fatigue on hospital personnel and its relationship to medical error, studies
outside the medical field demonstrate the potential link between fatigue and poor performance. Several
behavioral studies have shown that the slow‐wave activity achieved through sleep is strongly correlated with
improved performance in tasks. There is also a strong relationship between memory consolidation and sleep.
According to Dean, et al (2006) aging may also play a role when assessing the effects of sleep deprivation on
performance. There is evidence to suggest that the aging process increases the physiological and cognitive
effects of fatigue. Recent laboratory studies documented a decrease in performance in older workers on the night
shift compared to a younger worker. Crofts (1999) found that the problem with a night shift work is that the
human race is diurnal, who are functions during day time and night workers report a number of health problems.
Grafts added, these negative effects have consequences not just for individual, but also for work place, as
decreased alertness and reduced job performance that could endanger human lives and affect the quality of care
at intensive care unit.
2.3.1 The Ergonomically Aspect of Shift –work (Circadian Rhythm):
Akerstedt (1996) described the circadian rhythm is determined by the nucleus suprachiasmaticus in the
hypothalamus. This structure regulates the physiology and psychology functions of the body such as body
temperature. Body temperature is often used as an indicator for circadian rhythms, reaching its maximum at
17:00 hrs and its minimum at 05:00 hrs. The basic principle underlying the rhythm variations is catabolism (the
breaking down and release of energy) and readiness for action during the day, and anabolism (regeneration) and
rest during the night. According to Pheasant (1991) the word circadian comes from the Latin "circa dies" which
means” about a day, “Circadian rhythms are partly driven by the internal “body clocks” and partly synchronized
to the external world by cues know as zeitgebers (German: Ziet, time; Geber, giver). These rhythms are
coordinated to allow for high activity during the day and low activity at night. Normally the body uses cues from
its processes and from the environment such as clock time, social activities, the light / dark cycle, and meal times
to keep the various rhythms on track. The shift-worker’s temperature rhythm and other body rhythms get out of
phase with the persons activity pattern. This disorientation can lead to feeling of fatigue and disorientation. “Jet
lag” is a term, often used to describe these feelings.
Grandgean (1995) stated that the human organism was in its ergo tropic phase (geared to perform) in
the daytime and in its trophotropic phase (occupied with recuperation and replacement of energy) during the
night. Thus night worker does not-have the mood for performance, but in the relaxed phase of his cycle.
Ergonomics is therefore faced with the problem of planning work schedules in such a way that shift-work does
as little harm as possible to health and social life. Rodgers et al (1986) described the physiological processes that
take place within the human body as biological rhythms. Biological rhythm refers to any cyclic change in the

51
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

level of a measure or chemical in the body. Adrenal corticoids or thyroid hormone, are examples of hormones
that can cause changes in the body. Below is a list of circadian bodily functions that increase by day and
decrease by night. Body temperature, Heart rate, Blood pressure, Respiratory volume, Adrenaline production,
Excretion of 17-keto-steroids, Mental abilities Flicker-fusion Frequency of eyes and Physical capacity
Other time-keepers are changes from light to dark and vice versa, social contacts, work and knowledge
of clock time. The most important function that is geared to circadian rhythm is sleep. It is said that sleep that is
undisturbed either in quality or in quantity is a pre-requisite for health, well – being and efficiency ( Canadian
Centre for Occupational Health and Safety (CCOHS) , 1998).
The disturbance of circadian rhythms can affect concentration, motivation, and reaction time,
particularly at night. This combination can result in an increased risk of accidents and injury. Studies show that
shift-workers’ accident rates are more than day workers, the same or less. Thus, the findings do not conclusively
indicate that night shift workers are more prone to accidents. There are also discrepancies with research on this
issue because of the fact that working conditions are not the same on different shifts. For example, the nature of
workload, the backup system available and the amount of supervision can make comparisons inaccurate.
Nonetheless, lack of sleep heightens the decline in performance. When deprived of sleep the worker may not be
fully aware that performance has deteriorated. Research has shown that the optimum mental performance level
for workers occurs between 2 and 4 pm, maximum general awareness is between one, and 7 p.m. performance
levels are lowest between 3:30 and 5:30am, (CCOHS, 1998 www.ccohs.ca/oshanswers/work-
schedules//shiftwrk.htm1).
2.3.2 Physiological factors- sleep affect on professional nurse's performance
Akerstedt (1996 ) said that lack of sleep is one of the main reasons why irregular hours cause ailments and
disorders. Extended waking leads to tiredness and reduced functional capacity. The effects are initially
noticeable mostly if the individual is exposed for longer periods to a monotonous situation. After the first 24
hours without sleep. The functional capacity may be halved and after two sleepless days, the functional capacity
is at its lowest and the risk of falling asleep is ever present. With prolonged exposure, the individual cannot
manage to keep awake. Another aspect of tiredness concerns the ability to make complex decisions, which
require thinking.
Education and training development: The education and training development among nurses are important,
therefore, nurses working in hospital must generally be encouraged to participate in training and development
programs (Bhaga, 2010). They must be empowered with information and skills to remove feelings of inadequacy,
the shortage of the skills and information provided for professional nurses in health care system will affect their
performance negatively and make them dissatisfied from their organizational policy.
Effects of education and training development on professional nurse's performance:
Inadequate knowledge, skills and inappropriate attitudes can all form obstacles to good health care workers.
Advances in insights into treatment and diagnosis, as well as changes in roles and responsibilities, require
continuous professional development among health workers. In fact, a lifelong learning process must be
developed at the start of a professional career in the health sector (WHO, 2006).
2.4.1 Training:
Training is generally focused on teaching staff specific skills and concepts or altitudes. Training serves to
provide the nurse with specific skills or to reinforce previously learned behavior (Fottler et al., 1998).
In – service training:
In- service training is about facilitating learning and development of an employee while rendering a service to an
organization (Booyens 1993).According to Swans Burg (1999) In service education provides learning experience
in the work setting for the purpose of refining new skills.” In an organization, managers and supervisors are
responsible for developing employee’s potential and abilities to perform, and helping them adjust to rapidly
changing Job requirement. Supervisors, therefore, should continuously assess gaps and the potential abilities of
their subordinates in order to provide planned in- service training to correct matters (Boyens 1993, price 2000). It
is concerned with teaching staff skills, facts, attitudes, behavior and concepts through internally generated efforts
Fottler et al (1998).
2.4.3 Orientation training:
According to Libler & Mc Connell, (2004) each newly appointed employee invaded in an orientation
programmed. Ideally the formal orientation is brief, highly focused and completed on the worker’s first day. The
purpose is to introduce the staff member to the moves, behaviors and expectations of the organization.
Continuous education
Continuous education programs in organization are aimed at updating employee’s knowledge and competency in
order to improve their ability to analyze complex health problems, deliver and maintain health services and
sustain professional inter personal relations ships ( Booyens 1993; swans burg 1999). According to Booyens
( 1993) and Swans Burg (1999) , continuous education is usually part of self development responsibility to
ensure that their staff are kept up-to- date with new development. This may take the form of workshops,

52
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

conferences seminar, self learning modules, individual studies or degree courses. Continuing education is
professional learning experiences designed to augment knowledge, skills and attitudes of nurses and there by
enrich the nurse's contribution to quality health care and their pursuit of professional career Goals. Continuing
education usually relies on external training resources to accomplish. Its objectives ( liebler & Mc Connell,
2004). Kelly (2007) stated that continuing development of one’s professional skills and knowledge is an
empowering experience, preparing the nurse to make decision with the support of an expanding body of
knowledge. Mc Connel (2003) argue that in addition to increasing knowledge, improving skills and changing
attitude as Job performance requires, continuing education creates as learning attitude among employee. It can
therefore, be said that training and development increases an individual’s capabilities and improves the potential
effectiveness of all members of the work group with ultimately improve the ability of the organization to
perform us better. However, a heavy load of in – service training activities.

1.4 Performance: Means the actual conduct of activities to meet responsibilities according to standards. It is an
indication of what is done and how well it is done (Awases, 2006). According to WHO health report ( 2006), the
performance is a combination of staff being, available, competent, productive and responsive; poor performance
of service providers leads to inaccessibility of care and in appropriate care, which thus contribute to reduced
health outcomes as people are not using services or are mistreated due to harmful practice, it results from too few
staff or from staff not providing care according to standards and not being responsive to the patients need. As
Hughes et al. Stated "most performance problems can be attributed to unclear expectations, skills deficits,
resource or equipment shortages or a lack of motivations" (Hughes et al., 2002)
The term "performance" is used to focus attention on the total behavior of person including his or her
organization, the use of specialized knowledge, his/her attitude acquired through training, as well as organization
and integration of practice (Bargagliotti, 1999).
A performance related behavior is directly associated with job tasks and the need to be accomplish to
achieve jobs objectives (Sullivan and Decker, 2009). Performance evaluation is a continuous process with little
psychological risk to the employee. It is that constant feedback from one human being to another, which accept
the problem and tries to solve them (Young, 1992). Performance assessment is an essential requirement for the
evaluation of existing health services, and thus is necessary for improvement in health care by focusing on what
the health workers actually do (Jurnm, 1996).
Al-Ahmadi, (2009) study about factors affecting performance of hospital nurses in Riyadh Region,
Saudi Arabia, the study objectives were to estimate self-reported performance, and determine whether
differences in employee demographics, job satisfaction, and organizational commitment, influenced performance.
The study found that job performance was positively correlated with organizational commitment, job satisfaction
personal and professional variables. and strong predictors of nurses' performance. Job performance is positively
related to some personal factors, including years of experience, nationality, gender, and marital status, while the
level of education is negatively related to performance. This study concluded that it fulfilled a research gap in the
area of nursing performance, and its relationship with work attitudes and highlighted the impact of national
culture on job performance and work attitude among nurses in Saudi Arabia. Hong Lu, et. al (2004), argues that
the current nursing shortage and high turnover is of great concern in many countries because of its impact upon
the efficiency and effectiveness of any health-care delivery system. Recruitment and retention of nurses are
persistent problems associated with job satisfaction. This paper analyses the growing literature relating to job
satisfaction among nurses and concludes that more research is required to understand the relative importance of
the many identified factors to job satisfaction. It is argued that the absence of a robust causal model
incorporating organizational, professional and personal variables is undermining the development of
interventions to improve nurse retention.

1.5 Professional nurse: means a person registered with the nurse regularity and registering authority of their
country. Professional nurses are trained at higher education level with the training period between 3-4 years and
above. Professional nurses are also called registered nurses working in clinical, nursing services and educational
institutions (Awases, 2006).Their functions include assessing and educating patients, administering treatments
and supervising and coordinating care (Bureau of labor statistics, 2008).

2. Subjects and Method

2.1 Aim of the study: The study aimed to assess night shift and education/ training development factors on
performance of professional nurses in north West Bank governmental hospitals

2.2 Objectives of the study

1. Determine the affects of the night shift on the performance of professional nurses.
3. To assess how education and training development affect professional nurses performance.

53
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

2.3 Research hypothesis

1. There is no significant differences at the level of (α ≤ 0.05) between the means of night shift, education and
training development factors affecting professional nurses performance due to age variable.
2. There is no significant differences at the level of (α ≤ 0.05) between the means of night shift, education and
training development factors affecting professional nurses performance due to gender variable.
3. There is no significant differences at the level of (α ≤ 0.05) between the means of night shift, education and
training development factors affecting professional nurses performance due to workplace variable.
4. There is no significant differences at the level of (α ≤ 0.05) between the means of night shift, education and
training development factors affecting professional nurses performance due to the years of experience variable.
5. There is no significant differences at the level of (α ≤ 0.05) between the means of night shift, education and
training development factors affecting performance of professional nurses due to the academic degree variable.
2.4 Study design: Descriptive cross sectional explorative study was used for conducting the study.

2.5 Study Setting: This study was conducted on the governmental hospitals of the north part of West Bank,
these were Dr. Khaleel Suleiman hospital (Jenin Governmental hospital), Dr. Thabet Thabet hospital (Tulkarim
Govermental hospital), Dr. Darweesh Nazal hospital (Qalqelia Governmental hospital), Alwatani medical
hospital (Nablus governmental hospital), Rafedia surgical hospital, and Yasser Arafat hospital (Salfeet
governmental hospital).

2.6 Study period: The study was conducted from 1 June 2012 to August 2012.

2.7 Study Sample: A stratified random sample was selected, the sample of the study consisted of (185)
professional nurses with response rate 97% who were selected as a stratified random sample from the whole
population (315).

2.8 Inclusion criteria

Participants included in this study were stratified random sample of professional nurses (3 years and above)
working in governmental hospitals in North part of West Bank, while practical nurses were excluded from this
study.

2.9Tool of the study: The study questionnaire was designed by the study investigator after scanning related
studies and literature. The questionnaire consisted of two sections: The first section consisted of personal data
about nurse's age, gender, work place, years of experience and academic degree.
The second section consisted of (2) domains and (22) statements to identify the night shift and
education / training development factors affecting performance of professional nurses in North West Bank
governmental Hospitals. The domains of the study are ; night shift with (10) statements, education and training
development (12) statements .
The questionnaire items were constructed using a 5-point likert –scale Accordingly, the scores of
responses of the nurses to each statement were calculated according to the five-point-scale, “Likert scale”, in
which strongly agree = 5 points, agree = 4 points, uncertain = 3 points, disagree = 2 points, strongly disagree = 1
point.

3. Validity and reliability of the study: The content validity of instruments was censured including all the key
concepts relevant to the research topic. The questions were formulated to cover selected organizational factors
and professional nurses' performance. This instrument was approved and evaluated by different experts including,
researcher, nursing educators and other experts in the faculty of educational sciences to evaluate initial contents
for validity, and the researcher's thesis adviser also assesses the instrument for wording, adequacy, and coverage
of items of the standard of nursing performance. After revising the items in questionnaire and summarizing the
expert's suggestions, modifications were made in wording and content. Some items were added but some others
were dropped. The Cronbach's alpha obtained from this questionnaire reliability was 0.863 which is considered
high and suitable for research purpose.

4. Pilot study: Before starting the actual data collection process, a pilot study was conducted, as a pretest for
the questionnaire in order to assess the appropriateness of the instrument and to detect if there is need for any
modification to be done. A sample consists for 10 professional nurses were made to ensure the validity of the
study where no changes or modification was needed. Each questionnaire took 15-20 minutes to be filled.

6. Data analysis: The quantitative data were entered and analyzed using the SPSS ( Statistical Package for
Social Sciences version 17.0), and the level of significance (α) was set at 0.05. Descriptive and inferential

54
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

statistical tests were used. Demographic and baseline variables were analyzed using Means, frequency,
percentage, and standard deviations. Hypothesis were tested and analyzed by using t. test and Anova one way
test.

7. Ethical considerations: The title and research methods were approved by the higher studies and nursing
committee of the faculty of health professions at Al-Quds University. Permission obtained to access the MOH
hospitals when approval of the director of hospital services was granted. The study participant received an
explanation about the purpose of the study, confidentially and sponsorship of the study. In addition, the
participants were informed about his/her right to refuse or to withdraw at any time during the study through the
informed consent attached with each questionnaire

8. Results: The results indicated a high level of agreement among study participants on the means of the
domains affecting performance of professional nurses in a descending form; night shift (79%), education and
training development ( 68.8%). (Table 1)
Table(1): Scores of night shift and education and training development Factors Affecting Performance of
Professional Nurses in Descending Form
No. Domain M SD % Level
1 Night shift 3.95 0.60 79.0 High
2 Education and training development 3.44 0.62 68.8 Moderate
Hypotheses 1: There are no significant differences at the level of (α ≤ 0.05) between the means of
Night shift and Education and training development factors affected professional nurses performance, which
may be attributed to age variable( Table 3).

Table (2): Frequencies, means, and standard deviations of Night shift and Education and training
development factors affected performance of professional nurses at North West Bank governmental
hospitals due to age variable
Domain Age Frequency Mean S.D
Night shift Less than 25 20 3.82 0.59
25‐29 60 3.94 0.62
30‐34 35 3.98 0.62
35‐39 39 4.02 0.56
40 and above 31 3.93 0.64
Total 185 3.95 0.60

Education and training Less than 25 20 3.46 0.62

development 25‐29 60 3.52 0.67
30‐34 35 3.40 0.50
35‐39 39 3.36 0.68
40 and above 31 3.44 0.61
Total 185 3.44 0.62
For the testing of this hypnosis, One Way ANOVA Test revealed no significant differences at the level
of (α ≤ 0.05) between the means of Night shift and Education and training development factors affected
professional nurses performance, attributed to age variable (table 3 )

Table (3): Results of One Way ANOVA to test the differences between the means of selected
organizational factors affected professional nurses’ performance due to age
Domain F Sig.*
Night shift 0.387 0.818
Education and training development 0.438 0.781
Hypothesis 2: There are no significant differences at the level of (α ≤ 0.05) between the means of
Night shift and Education and training development factors affected professional nurses performance, attributed
to gender variable. For the testing of this hypothesis, T-Test statistical analysis for independent samples was
performed. It was found that there were no significant differences at the level of (α ≤ 0.05) between the means of
Night shift and Education and training development factors affected professional nurses performance, attributed
to gender variable (Table 4) shows the results.

55
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

Table (4): Results of T-Test for independent samples T-Test used as the gender variable contains TWO
groups (male & female)
Domain Gender Frequency Mean S.D T- value Sig
Night shift Male 72 3.90 0.53 0.810 0.419
Female 113 3.98 0.65

Education and training Male 72 3.37 0.47 1.197 0.233

development Female 113 3.49 0.70
Hypothesis 3: There are no significant differences at the level of (α ≤ 0.05) between the means of
Night shift and Education and training development factors affecting professional nurses performance attributed
to the workplace variable (Table 5)

Table (5): One Way ANOVA to test the differences between the means of Night shift and Education and
training development factors affected professional nurses’ performance attributed to the workplace
Domain Hospital Frequency Mean S.D F Sig.*
Night shift Dr. Khaleel Suleiman 37 3.88 0.66 6.459 0.0001
Dr. Thabet Hospital 29 3.48 0.53
Dr. Nazal Hospital 18 4.21 0.49
Al-Watani Hospital 29 4.17 0.52
Rafedia Hospital 51 4.08 0.54
Arafat Hospital 21 3.84 0.58
Total 185 3.95 0.60
Education and Dr. Khaleel Suleiman 37 3.46 0.79 3.145 0.010
training Dr. Thabet Hospital 29 3.52 0.44
development Dr. Nazal Hospital 18 3.90 0.63
Al-Watani Hospital 29 3.21 0.39
Rafedia Hospital 51 3.38 0.65
Arafat Hospital 21 3.37 0.54
Total
For the testing of this hypothesis, One Way ANOVA was used. The results revealed significant
differences at the level of (α ≤ 0.05) between the means of Night shift and Education and training development
factors affecting professional nurses performance attributed to the workplace variable.

Hypothesis 4:
There are no significant differences at the level of (α ≤ 0.05) between the means of Night shift and Education
and training development factors affected professional nurses performance attributed to the Years of experience
variable. (table 7).
Table (7): One Way ANOVA to test the differences for years of experience
Domain Years of experience Frequency Mean S.D F Sig.*
Night shift Less than one year 12 3.95 0.74 0.452 0.771
1‐5 62 3.91 0.58
6-10 48 3.96 0.61
11-15 39 3.91 0.55
16 and above 24 4.09 0.70
Total 185 3.95 0.60
Education and Less than one year 12 3.49 0.42 0.100 0.982
training 1‐5 62 3.43 0.68
development 6-10 48 3.43 0.60
11-15 39 3.42 0.66
16 and above 24 3.51 0.58
Total 185 3.44 0.62
For the testing of this hypothesis, the researcher conducted One Way ANOVA Test. The result of this
analysis showed that there are no significant differences at the level of (α ≤ 0.05) between the means of Night
shift and Education and training development factors affected professional nurses performance, which might be
attributed to the Years of experience variable (Table 7).
Hypothesis 5: There are significant differences at the level of (α ≤ 0.05) between the means of Night
shift and Education and training development factors affecting performance of professional nurses attributed to

56
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

the Academic degree variable (9)

Table (9): One Way ANOVA to test the differences between the means of Night shift and Education and
training development factors to academic degree
Domain Academic degree Frequency Mean S.D f Sig.
Night shift Diploma (three years) 24 3.88 0.72 0.287 0.835
Bachelor degree (four years) 133 0.57 0.57
Postgraduate diploma 15 3.87 0.73
Master degree 13 4.05 0.63
Total 185 3.95 0.60
Education and Diploma (three years) 24 3.34 0.55 1.549 0.203
training Bachelor degree (four years) 133 3.46 0.61
development Postgraduate diploma 15 3.64 0.77
Master degree 13 3.18 0.63
Total 185 3.44 0.62
One Way ANOVA test revealed no significant differences at the level of (α ≤ 0.05) between the means
of Night shift and Education and training development factors affecting performance of professional nurses
attributed to the Academic degree variable except the domain of resources availability. (Table 9)

9. Discussion: The majority of professional nurses were bachelor degree (71.9%), while (32.4%) of the
participants (25-29) years old. There was a bias in the distribution. On the other hand, the majority were female
(61.1%) as opposed to (38.9%) males. It was found that 32.4% of the participants were 25-29 years old, 21.1%
aged 35-39 years old, 18.9% aged 30-34 years old, 16.8% aged 40 and above years old, 10.8% aged less than 25
years old. However, there were no significant differences at the level α ≤ 0.05 between means of organizational
factors affected professional nurses performance which might be attributed to the age variable. This means that
the age of the participant had no effect on the organizational factors affected professional nurses’ performance at
the selected hospitals. The majority of respondents age range between 25-29 years old (32.4%). This result
could be interpreted by the following: the nurses with long experiences in the hospitals prefer to move to public
clinics so as to get rid of evening and night shift duties, this movement give chance for new professional nurses
to be hired by hospitals, and also the application of the law in the civil service and the Palestinian MOH, which
gives the chance for early retirement of (50 years old) for females or after 20 years of experience, so many
nurses now scheduled on the program of retirement according to this law, and the MOH starts to replace the
nurses with new graduated.

9.1 Gender
It was found that the majority of participants were female (61.1%) as opposed to (38.9%) males. There was no
significant differences at the level α ≤ 0.05 between the mean of organizational factors affected professional
nurses performance at north west bank governmental hospitals due to gender. it was found that gender of the
participants had no effect on their on the organizational factors affecting professional nurses performance at the
selected hospitals Through the study results it was congruent with the result of Awads study (2004) where males
formed most of respondent, they were congruent with the study of Elkahlout & Algaed (2003) however, most of
the nursing staff are females, they 88% of the population of nurses and the rest 12% are males . It should note
that nurses is a female profession and needs female more than males. The Palestinian Central Bureau of Statistics
(2003) found that the percentage of female nurse was nearly 63.0%as opposed to 37% males.

6.1.5 Academic degree

The majority of participants (71.9%) had a bachelor degree, (13%) had a diploma three years degree, (8.1%)
have post graduated diploma degree, (7%) had a master degree. This result is inconsistent with the literatures that
focused on the importance of the educational level for nurses because it determines their responsibilities for
performing the various roles (Jacob, 2002). According to Kane, et al (2007) found that there is a relationship
between registered nurses and the quality of nursing outcome, decreasing mortality rate, decreasing
complications, and infection among nurses.
However, the researcher found that there were no significant differences at the level of α=0.05 between
the means of selected organizational factors affecting professional nurses performance at north west bank
governmental hospitals which might be attributed to academic degree of participants.
6.3.1.2 Nightshift affected professional nurses' performance:
This subcategory consists of ten items related to Nightshift statement reflecting the professional nurses’
performance effectiveness to identify the Nightshift statement at the professional level. The results indicate the
total mean of Nightshift affecting professional nursing performance in selected North West bank governmental

57
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

hospitals:3.95, SD. 0.60. the percentage 79% that was high, which might be attributed to the majority of
participants (79%) who agreed on all items included under this subcategory.
Statement, night shift makes some nurses physically exhausted (88.8%), night shift makes some nurses
unwilling to work next day (87.2%), night shift makes some nurses frustrated (85.8%) and nurse’s shortage
forces to working extra shifts adding extra workload (85.8%) achieved a very high level of organizational factors
affecting professional nurses performance in the Nightshift domain
This result that the nurses regarded the time of 10 hours allocated for either the day shift or night shift
as too long. Circadian rhythms can get out of phase with an abrupt change in an individual's activity, certain
nurses take a long time to adjust to changes due to internal clock rhythm and inability to keep track with the time
cues results in a person being frustrated. Nurse’s shortage forces to working extra shifts adding extra workload
(85.8%), the temporary supporting night nurses not as competent as permanent staff to deal with peculiar
problems encountered in specialized units. This make it necessary for night nurses to work extra hard shift to
keep their sections functioning to the desired health care standard and also the workload of the night nurses is
dependent on the intake of patients during a particular day.
This result agree with Madide (2003), that there is a diversity of problems encountered by nurses in a
normal working situation. Some of these may be physical, physiological, psychosocial, socio-economic and
cultural or health related. Night work intensifies problems since the individual is working when the body clock is
naturally telling the majority of the people to rest. 50% of the respondents working on day shift indicated that
they do not get enough sleep due to night shift, whilst only 18% of nurses complain of a lack of sleep after
working on nightshift. The researcher observation is 88.8% of participants are physically exhausted due to the
nightshift. The researcher opinion is problems vary with each individual since the biological structure is different,
some nurses physically exhausted due to the night shift, unwilling to work next day, frustrated and their shortage
forces to work extra shift adding extra workload.
According (pheasant,1991) the general state of bodily exhaustion which , results from prolonged heavy
work, is the depletion of the body's energy reserve, fatigue which results from most occupational tasks, is due to
more suitable psycho physiological processes. fatigue is the feeling of abnormal tiredness, lethargy and loss of
drive .
Behar et. al.( 1999) the symptoms reported by night –shift nurses include sleepiness, sadness and
difficulty concentrating, with numerous complaints about cumulated fatigue and disturbed social life.
While the statements, night shift increase rate of absenteeism among nurses (75.4%), night shift affects
nurse attitude toward their practice and profession (75.2%), night shift increases turnover (75.0%), there is a low
concentration among nurses during night shift (74.0%) and night shift allow for more error and accident (72.6%)
achieved a high level. While the statement night shift decrease quality of service provided to patients (69.8%)
achieved moderate.
The influence of circadian rhythm on the night worker difference in the circadian rhythm make other
worker to be at their peak in the evening and some to reach their peak in the morning Meckenzie J (2001) The
study also examined if nurses felt more when working on night shift . the result show that 67% of nurses did not
feel energetic. Tiredness may be due to insomnia, changes in sleeping patterns, variation in length of shift period,
and circadian rhythm. The fact that about 20% of the respondent experienced persistent tiredness implies that
their performance could be impaired. This inefficiency in performance could have deleterious consequences on
the health care of patients.
The researcher found that sleep has major effects on the health and the performance of nurses . The
health care worker in this have indicated that are exposed to any error or accident resulting from fatigue or stress
can cost a life patients.
Ohida, "et al" (2001) find that in examining the influence of day, afternoon, night and rotating shifts on
job performance and stress on nurses, found that job performances and satisfaction was less on a rotating roster
than on a fixed roster. Although there has been a move towards studies of nursing turnover, there is still a
general absence of research that attempts to associate perceptions of night duty with job satisfaction and
ultimately staff turnover.
6.3.1.4 Educational and training development affected professional nurses' performance:
This subcategory consist of thirteen items related to Educational level statement reflecting the professional
nurses performance effectiveness to identify the Educational level statement at the professional level. The results
indicate the total mean of Educational and training development affecting professional nursing performance in
selected north west bank governmental hospitals: 3.44, SD. 0.62. the percentage 68.8% that was high, which
might be attributed to the majority of participants (68.8%) who agreed on all items included under this
subcategory.
The result agree with Benti, et. al. (2006) said, that training is any process by which the aptitudes, skills,
and abilities of employees to perform specific jobs are increased. It is the act of increasing the knowledge and
skills of an employee for doing a particular job. Abruzzese (1996) stated that because the health care delivery in

58
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

hospitals become complex, the need for continuous skilled training becomes also increasable.
While the statements, nurses are well trained to protect themselves against hazards and professional
errors (74.2%), error and accidents are referred to lack of competence (74.2%), absenteeism is referred to low
competence (73.8%) and professional nurses participate in identifying their staff development needs (70.0%)
achieved a high level.
The American Nurses Association (ANA, 1991) emphasized on the ongoing educational activities for
nurses, because it helps in enhancement of practice relevant to their responsibilities, professional growth, and
maintaining competency in their respective positions. Ward and O’Brien (2005) supported that the division of
nursing ensures development of educational programs to support the delivery of high quality nursing care.
Bahaga (2010) found that 50% respondents believe that they are given sufficient information to protect
themselves against hazards that may occur in their work. However 26.47% respondents believe that they are not
provided sufficient information to protect themselves against hazards that may occur in their work. The
researcher opinion that all the professional nurses should be given sufficient information to protect themselves
from hazards in their work. While the statements, there is an increase in patient complains due to the lack of
skills and knowledge provided to nurses (69.2%), there is continuous education and training are provided to
nurses (67.6%), education and training provided responses to the nurses training needs (66.6%), nurses education
and training needs are systematically identified (66.2%), in service training adequately addresses performance
gaps (65.6%) and continuous education and training are provided fairly to all nurses (61.6%) are achieved
moderate level. While the statement, there is a clear policy for training nurses (56.8%) is achieved low level.

10. Conclusion
The night shift and education/ training developmental factors affected the performance of the professional
nurses. Dr. Nazal Hospital found to be the highest mean of night shift and education/ training developmental
factors affecting nurses' performance. Dr. Thabet Hospital was the less mean according night shift while Al-
Watani according to education/ training developmental factors.

11. Recommendation: let nurses assign appropriate shifts, reduce the strain of long work hours on night shift
and motivation could improve adaptation of the nurses toward work hours of night shift. Providing continuous
professional development of nurses in service training program. Further research is needed to validate these
results.
.
12. Acknowledgement:
The researchers are grateful to the nurses in the targeted governmental hospitals for the participation in this
study, to the Ministry of health administration of Palestine for help and support.

13. References
MOH Report, (2011) Health Annual Report Palestine.
WHO report, health conditions in the occupied Palestinian territory, including east Jerusalem, and in the
occupied Syrian Golan, 2011.
Awases MH. 2006. Factors affecting performance of professional nurses in Namibia. [PhD thesis]. University of
South Africa, South Africa.
Page, A. (Ed). (2004). Keeping patients safe: transforming the work environment of Nurses. Washington, DC:
National Academies Press.
Bhaga, T. 2010. The Impact of Working Conditions on the Productivity of Nursing Staff in the Midwife
Obstetrical Unit of Pretoria West Hospital, Department of Social Work & Criminology, Faculty of
Humanities, University of Pretoria, Pretoria.
Bargagliotti, T., Luttrell, M, & Lenburg, C.B. (Sept 1999). Reducing threats to the implementation of a
competency-based performance assessment system. Online Journal of Issues in Nursing. Washington,
DC: Amer Nurs Assoc.
Ohida, T. kammal, A. Ishii, T., uchimyama, M., Minowa, M, Nozaki, S. (2001) Night Shift work Problem in
young Female Nurses in Japan. Journal of occupational Health 43, 150-156.
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington,
DC: The National Academic Press.
Rogers, A.E., Hwang, W.T., Scott, L.D, Aiken, L.H., and Dinges, D.F. (2004) the working hours of hospital staff
nurses and patient safety. Health Affairs, 23, 202-212.
Akerstedt, T., (1996). Wide Awake at odd hours. Shift work, time zones and burning the midnight oil. Swedish
Council for working life. Stockholm. Pages: 10-11.
Allen C. (1999) Summary of the Crost Seminar: shift work retrieve from Oregon Health and Science University
on March/10/2004 website httpi//www.obsu.ed/croet/outreach/symposia/shiftwork.html.

59
Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.6, No.27, 2015

Akerstedt, T., Knutsson, A., Westerholm, P., Theorell, T., Alfredsson, L., & Kecklund, G. (2004). Mental fatigue,
work and sleep. Journal of Psychosomatic Research, 57, 427–433.
Dean, G., Scott, L., and Rogers, A., (2006) infant at risk: when nurse fatigue Jeopardizes quality care. Advances
in neonatal care, 6(3) PP 120-126.
Crofts L ,(1999). Challenging Shift work: A review of common restoring practices
Grandjean, E.,(1995). Fitting the task to a Man. A text book of Occupational Ergonomics. Fourth Edition. Taylor
Francis. London Pages 217-230.
Rodgers, S.H, Liser, D.M: Muphy, T.J: Nielsen W.J. (1986). Ergonomics for people at work. Volume 2. Estman
Kodak Co. US. A. Pp 72-73.
Canadian center for occupational health and safety,( 1998). Rotational shift-work.
(httpi//www.ccohs.ca/oshanswers_schedules/shiftwrk.html).
WHO (2006). World health report 2006. Working together for health. Geneva, World Health Organization
(http://www.who.int/whr/2006/en/, accessed 25 April 2006).
Fottler, M.D. Hernandez, R. and Joiner, C.L.,(1998).Strategic Management of Human Resources in Health
services organization. New York : A witey Medical Publication.
Booyens, SW.,( 1993), Staff development in Dimension of nursing management, edited by SW Booyens.
Kenwyn: Juta: 365-383.
Swansburg, R.C. (1993). Introducing Management and leadership for clinical Nurses: A Text workbook. 2nded.
London: Jones and Bartler publishers.
Swansburg, RC and Swansburg, RJ. (1999). Introductory management and leadership for nurses. 2nd edition.
Sudbury: Jones and Bartlett publishers
Liebler, J,G and McConnell, C.R. (2004). Management principle for health professionals. 4thed. London: Jones
and Bartlett publishers.
Kelly, K.( 2007). Power, politics and influences. In Yonder-wise, P.S.(Ed) leading and management in Nursing.
4thed. Texas : Mosby.
McConnel, C.R.,(2003). The effective health care supervisor. 5thed. London: Jones and Bartlett publishers.
Bureau of labor statistics. (2008) Occupational outlook handbook: registered nurses (2008-2009 ed.).
Washington, DC: U.S. department of labor. Retrieved April 30, 2009, from httb:
//www.bls.gov/oco/ocos083.htm.
Hong Lu, Alison E. While, K. Louise Bariball, (2004), Job satisfaction among nurses, Florence Nightingale
School of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57
Waterloo Road, London SE1 8WA, England, UK.
Jurnm, L.s. (1996). Nursing Evaluation: Purpose, Achievements and Opportunities. (2th ed.) Tokyo Co, p231-
237.
Al-Ahmadi, (2009) "Factors affecting performance of hospital nurses in Riyadh Region, Saudi Arabia",
International Journal of Health Care Quality Assurance, Vol. 22 Iss: 1, pp.40 – 54
Sullivan, E.J & Decker, P. J. (2009). Effective Leadership and Management in Nursing. 7th ed. New Jersey:
Pearson Prentice Hall.
Hughes RL, Ginnett RC, Curphy GJ, (2002). Leadership, enhancing the lessons of experience (4th ed.). New
York, McGraw-Hill/Irwin.
Awad, Y. (2004). "Gaza Nurse Perception about nursing Continuing Education-Palestine."
Elkahlout & Algaed (2003) Effect of some Socio-Demographic Factors on Job Stress Level in Nursing Work.
The Palestinian Central Bureau of Statistics (2003).
Kane, R., Shamliyan, T., and Mueller, Ch.(2007). Nursing Staffing and Quality of Patient Care.Evidence Report/
Technology Assessment. AHRQ Publication .
Pheasant, S.T. 1991. ERGONOMICS, WORK AND MACMILLAN PRESS. London. Pp 3-4, 156-157, 185-188.
Ward, A. K., and OBrien, H.L.(2005). A gaming Adventure. Journal for Nurses in Staff Development, 7(5) p.
220-224
ANA, (2011), nurses standards report, www.nursingworld.org
Abruzzese, R. S. (1996). Nursing Staff development Strategies for Success. (2nd ed). St Louis, Mosby, pp 36-38
Benti W., Meseret M., & Yigremew A., (2006) Introduction to management. Addis Ababa: Alem Printing Press.
Behar, P, Tilley. A.J (1999). The impact of night work on psychological well being. Ergonomics Journal, 32,
1089-1099.
Mckenzie, J(2001).Circadian Rhythms and Emergency Medicine Practice, Emergency Medicine Journal. 21,
(10), 1250-1258.
Madide S, 2003, Effects of Night Shift Schedules on Nurses Working in a Private Hospital in South Africa.
ISSN: 1402 - 1617

60
The IISTE is a pioneer in the Open-Access hosting service and academic event management.
The aim of the firm is Accelerating Global Knowledge Sharing.

More information about the firm can be found on the homepage:

http://www.iiste.org

CALL FOR JOURNAL PAPERS

There are more than 30 peer-reviewed academic journals hosted under the hosting platform.

Prospective authors of journals can find the submission instruction on the following
page: http://www.iiste.org/journals/ All the journals articles are available online to the
readers all over the world without financial, legal, or technical barriers other than those
inseparable from gaining access to the internet itself. Paper version of the journals is also
available upon request of readers and authors.

MORE RESOURCES

Book publication information: http://www.iiste.org/book/

Academic conference: http://www.iiste.org/conference/upcoming-conferences-call-for-paper/

IISTE Knowledge Sharing Partners

EBSCO, Index Copernicus, Ulrich's Periodicals Directory, JournalTOCS, PKP Open

Archives Harvester, Bielefeld Academic Search Engine, Elektronische Zeitschriftenbibliothek
EZB, Open J-Gate, OCLC WorldCat, Universe Digtial Library , NewJour, Google Scholar